Consent and Application for Remittance of Disability Benefits to an Insurer - Québec Pension Plan

Insurance companies can use this form to obtain an applicant's consent to the reimbursement of disability benefits to the insurer. This form is also used to file the insurer's application for remittance.


By signing this form, you are agreeing to file an application subsequently for disability benefits with Retraite Québec. We recommend that you review the clauses of your contract with your insurance company because you may not be required to complete the form.

RRQ-004 form. Last update: May 2023.

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